BIOBRIEF

Ramal Bone Graft for Congenitally Missing Maxillary Lateral Incisor

Dr. Richard E. Bauer, III

THE SITUATION

An 18-year-old female presented with a congenitally missing tooth #10. The patient previously sought care by another provider and had undergone guided bone regeneration with allograft and subsequent implant placement with additional grafting at the time of implant placement. The implant ultimately failed and was removed prior to my initial consultation. An examination revealed maximal incisal opening, within normal limits, missing #10 with 6 mm ridge width. In addition there was a significant palpable cleft-like depression on the facial aspect of the ridge, adequate attached tissue but reduced vertical height in relation to adjacent dentition and attached tissue. Previous surgeries resulted in extensive fibrous tissue with scarring at site #10. Plan: A ramal bone graft is indicated at the congenitally missing site #10 with Geistlich Bio-Oss® and Geistlich Mucograft® matrix utilized for ridge augmentation prior to secondary implant placement.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

The goals for this patient are to reconstruct the osseous foundation and provide a matrix for improvement with the overlying soft tissue. Specifically, a coordinated multidisciplinary plan was established with the restoring dentist, periodontist and oral surgeon. A plan for idealized anterior cosmetic prosthetic restoration was established. Sequencing of treatment was established. Surgical phase one included a ramal bone graft to site #10 and Essix type temporary prosthesis for immediate post-operative phase followed by a temporary Maryland bridge. Surgical phase two included implant placement and simultaneous crown lengthening and osteoplasty. This stage was done with immediate provisionalization.

A flap has been raised and reveals a significant facial and palatal defect at congenitally missing site #10.

Harvested ramal graft. Slightly over-sized to allow for mitering and harvest of particulate autograft with a bone trap on the suction.

Onlay graft now secured with two fixation screws (Stryker) with a lag screw technique. Geistlich Bio-Oss Collagen® has been placed on the palatal aspect of site #10

Combination of a fixated onlay graft with Geistlich Bio-Oss®/autograft particulate graft at the periphery and over the facial plate of the adjacent dentition

Geistlich Mucograft® matrix placed over facial augmentation of the adjacent dentition and ridge crest of the augmented site

Closure following ramal grafting and Geistlich Mucograft®matrix application

Implant placement with static guide and dental implant hand driver

Implant placement with slight subcrestal placement of the platform just prior to osteoplasty by the periodontist.

“This is a young patient with a congenitally missing incisor that has high esthetic concerns and has had multiple failed surgical attempts that is now presenting for definitive management.”

THE OUTCOME

This case was dependent upon adequate hard-tissue reconstruction combined with soft-tissue manipulation to eliminate scar tissue and provide esthetic recontouring. Obtaining an adequate autogenous graft combined with Geistlich Bio-Oss® at the periphery of the onlay graft is essential for anterior-posterior and vertical augmentation. Utilizing a Geistlich Mucograft® matrix at the ridge crest to help contain the particulate graft and improve the soft-tissue profile for subsequent immediate provisionalization and re-contouring of the surrounding soft tissue played a significant role in the esthetic success.

Immediate provisional in place two days after implant placement and osteoplasty. There has been significant gain in bony architecture and development of soft-tissue contours at a site that was extremely deficient of structure to begin with.”
Dr. Richard E. Bauer, III

Dr. Richard E. Bauer, III

Oral and Maxillofacial Surgeon – University of Pittsburgh

Richard E. Bauer, III, DMD, MD is a graduate of the University of Pittsburgh Schools of Dental Medicine and Medicine. Dr. Bauer completed his residency training in Oral and Maxillofacial Surgery at the University of Pittsburgh Medical Center. Dr. Bauer has served on multiple committees for the American Association of Oral and Maxillofacial Surgery (AAOMS). He is a full-time faculty member and Residency Program Director at the University of Pittsburgh in the department of Oral and Maxillofacial Surgery and his practice is focused on dental implants and corrective jaw surgery. He has been active in research with focus on bone regeneration and virtual applications for computer assisted planning and surgery.

WEBINAR

CLINICAL CASE

1 – Extraction of tooth 21 due to a trauma with concomitant external resorptions. Care was taken in preserving the alveolar bone.

2 – Crestal view of the socket after tooth extraction. No flaps are raised around the affected area. A slight buccal bone defect was observed.

3 – The socket is gently curetted for removal of granulation tissue. Subsequently, the wound margins were de-epithelialized with a diamond in a counter piece with water cooling

4 – Filling of the extraction socket with Geistlich Bio-Oss® Collagen to the level of the palatal bone

5 – After measuring the alveole, Geistlich Mucograft® is punched (8 mm diameter

6 – The Geistlich Mucograft® punch is placed on top of Geistlich Bio-Oss® Collagen to seal the filled alveole.

7 – Suturing of the Geistlich Mucograft® with 6-0 single interrupted sutures.

8 – Nice healing of the soft tissues 1 week after extraction.

9 – Situation 7.5 months after extraction revealing nice soft tissue situation with a slight dip at the buccal aspect.

CLINICAL CASE

1 – Pre-operative situation, tooth #7 with periapical infection and horizontal fracture.

2 – CT Scan showing tooth #7 with significant bone loss.

3 – Occlusal view of the clinical situation prior to extraction of tooth #7.

4 – Extraction socket with Geistlich Bio-Oss Collagen® in place.

5 – Geistlich Mucograft® Seal is placed over the extraction socket and secured with single interrupted sutures.

6 – 3 months post-operative: soft tissue healing at the time of implant placement.

7 – Buccal view showing excellent soft tissue healing and keratinized tissue.

9 – 2 years post-operative: final restoration in place.

CLINICAL CASE

Initial Situation: a failing mandibular molar with a vertical sub-osseous fracture.

A pre-operative radiograph and CBCT showing the cross-section of the involved tooth.

An implant site was developed by placing a pilot drill down the mesial root space, then uprighting it. This was continued up through the drill sequence. The mesial radicular septum is moved in the process.

A Camlog® 5.0 x 11 mm implant was placed with the platform set just down below the bone height of the socket walls.

After placing a 4.0 mm height cylindrical gingiva former in the implant, 250 mg of Geistlich Bio-Oss Collagen® was packed down in the socket around the implant.

Geistlich Mucograft® was adapted to the region then tucked down under the gingival margin.

The gingival margins were adapted and closed together with 4.0 teflon sutures (Cytoplast™, Osteogenics). The region was then covered with Glustich – PeriAcryl®90 Oral Tissue Adhesive.

4 months later following Emergence Profile Development.

An occlusal view of the final one-piece, screw-retained zirconia crown restoration based on a Camlog® Titanium Base Abutment.

CLINICAL CASE

1 – Pre-operative lateral smile showing the recession defect of tooth 5.

2 – Pre-operative image of recession defect (tooth 5).

3 – After elevation of split-full-split flap the interdental papillae are de-epithelialized.

4 – Geistlich Mucograft® is placed over the root and sutured to the papillae

5 – The flap is mobilized, coronally advanced and sutured completely covering the Geistlich Mucograft®.

6 – Healing of the surgical site 2 weeks after surgery.

7 – Surgical site 6 months after surgery.

9 – Lateral smile 1 year after surgery showing the optimal esthetic outcome.

CLINICAL CASE

1 – Before preparation of the flap the exposed root portion is cleaned with a scraper and is wiped with EDTA (or similar).

2 – After measuring the dimension of the recession defect using a periodontal probe, the incisions for raising the flap are cut.

3 – A split-full-split thickness flap is elevated and coronally mobilized.

4 – The area of the papillae is de-epithelialized to allow anchorage of the flap coronal to the cemento-enamel junction.

5 – Geistlich Mucograft®is applied dry to the defect and is fixed with 4 single sutures.

6 – The coronally advanced flap is sutured over Geistlich Mucograft®.

7 – Nice, uneventful healing 15 days post-operatively at suture removal.

8 – Soft tissue situation immediately after suture removal.

9 – Complete root coverage 7 months after surgery. Note the excellent color match.

CLINICAL CASE

1 – Pre-operative image showing the recession defect on tooth #6.

2 – After elevation of a partial thickness flap, the interdental papillae are de-epithelialized.

3 – Geistlich Mucograft® is placed over the defect and sutured to the papillae.

4 – The flap is coronally advanced and sutured completely covering the matrix.

5 – Follow-up after 1 week: healing of the surgical site.

8 – Follow-up after 6 months: note the natural appearance of the soft tissue achieved with Geistlich Mucograft®.

CLINICAL CASE

1 – Pre-operative picture of the area intended to treat. Note the thin biotype.

2 – Initial situation showing Miller Class I defects on region 4 (3 mm) and 5 (2 mm).

3 – A split-full-split thickness flap without releasing incisions is elevated.

4 – The anatomical papillae are de epithelialized.

5 – The collagen matrix Geistlich Mucograft® is placed under the flap.

6 – Immediate post-operative situation after suturing of the flap covering Geistlich Mucograft® completely

7 – Follow-up picture 2 weeks after surgery.

8 – Nice healing of the site 1.5 months post-operative.

9 – Pleasant esthetic outcome 7 months after surgery.

CLINICAL CASE

Pre-operative view of recession defects that ranges from 2-5 mm. There is minimal keratinized tissue on #14. Pocket depths are within limits with no loss of interproximal tissue.

A 15c blade is used to make sulcular incisions with scooping incisions at the level of the CEJ. A combination flap consisting of full-thickness coronally followed by a partial-thickness dissection apically is reflected.

The papillary tissue is de-epithelialized with a football diamond bur on a rotary hand piece. This exposes a vascular bed for the graft and intended coronal positioning of the flap.

Side-view of the recession defects. It is clearly visible how deep the recession defects are.

Geistlich Mucograft® is trimmed and positioned to extend beyond the root surfaces. A combination of simple interrupted sutures at its coronal edge and mattress sutures extending over the entire graft are used to adapt the graft to the recipient site.

The flap is then advanced and coronally positioned with horizontal mattress sutures to release tension and simple interrupted sutures to approximate the flap edges to the de-epithelialized papillas.

Follow-up after 1 week: note that the flap margins appear stable. Erythema and edema evident with maturation of the tissue beginning.

Follow-up after 3 months: maturation of the tissue evident with complete root coverage. An increase in the zone of keratinized tissue by #14 is also visible.

Follow-up after 1 year: stability of the graft is evident, complete coverage and a healthy and maintainable gingival situation have been achieved.

CLINICAL CASE

1 – This case shows a shallow vestibule and almost no keratinized tissue on the lower crestal part. The horizontal incision has to be made within the keratinized tissue (see depicted line).

2 – Ensure the incision is within the keratinized tissue: an apically fixed split flap is used here. Remove the muscles, scar fibers and ligaments before application of Geistlich Mucograft®.

3 – Measure the defect carefully with a periodontal probe and cut Geistlich Mucograft® in a dry state. In the case of a large vestibuloplasty, several pieces of Geistlich Mucograft® can be sutured side by side.

4 – Geistlich Mucograft® is sutured directly onto the periosteum with 5.0 resorbable sutures and left exposed for open healing (healed by secondary intention).

5 – 10 days post-operative: favorable healing where granulation tissue and new soft tissues have formed.

6 – 1 month post-operative: excellent wound healing with complete integration and epithelialization of Geistlich Mucograft® as well as keratinization of the crestal aspect could be observed.

7 – 3 months post-operative: excellent esthetic outcome with full integration and epithelialization of Geistlich Mucograft® to the surrounding tissue and keratinization of the crestal aspect.

8 – 1 year post-operative: the formed keratinized tissue fulfills its functionality and shows an esthetically pleasing result matching the structure and color of the surrounding tissues. The mean width of the peri-implant keratinized mucosa was 4.0 mm, and a low shrinkage was assessed at 38%.

9 – 5 years post-operative: the mucogingival appearance remains stable. The resulting keratinized tissue fulfills its functionality and shows an esthetically pleasing result.

CLINICAL CASE

1 – Pre-operative view. A small band of keratinized gingiva is present

2 – The band of keratinized gingiva is split and a split-thickness flap is elevated exposing connective tissue and periosteum.

3 – Geistlich Mucograft®is sutured to the recipient bed and left exposed.

4 – Follow-up after 1 week: the area appears to granulate underneath the fibrin clot.

5 – Follow-up after 4 weeks: excellent wound healing.

8 – Follow-up after 6 months: Lugol’s iodine staining indicates delineating keratinized tissue.

9 – Follow-up after 6 months: mucogingival appearance with 4 mm of keratinized tissue.

CLINICAL CASE

1 – Pre-operative radiograph showing the severe bone defect around the tooth.

2 – Six weeks after tooth extraction, uneventful soft-tissue healing in the post-operative phase is visible.

3 – After flap preparation, an implant was placed in a site with a severe bone defect.

4 – In order to fill up the defect and provide volume stability Geistlich Bio-Oss Collagen® was applied.

5 – After augmentation with Geistlich Bio-Oss Collagen®, the site was covered with a collagen fleece.

6 – Final crown restoration after 6 months post-operative.

7 – The radiograph after 25 years shows a stable bone situation.

8 – The clinical picture after 25 years follow-up presents a very nice and stable bone and soft-tissue situation.

CLINICAL CHALLENGE:

The upper premolar had to be removed due to advanced periodontal disease and severe bone loss around the infected tooth. The bone defect was an intra-alveolar defect without dehiscence or fenestration.

AIM/APPROACH:

An early implant placement approach with a healing time of six weeks before implant placement was chosen. The bone augmentation with Geistlich Bio-Oss Collagen^® was conducted simultaneously with implant placement. As this patient was treated in 1991, the case is one of the very first clinical applications of Geistlich Bio-Oss Collagen^®

CONCLUSION:

A premolar grafted with Geistlich Bio-Oss Collagen^® during implant placement showed good long-term result after 25 years. Satisfactory hard and soft-tissue contour are present 25 years after implantation.

CLINICAL CASE

1 – Pre-operative photograph showing the horizontal bone defect at sites #18 and #19

2 – Cone-Beam Computed Tomography (CBCT) showing the horizontal and vertical bone defects at sites #18 and #19

3 – Full-thickness flap reflection and buccal flap release to achieve tension-free primary closure

4 – Harvested autograft and vallos™ fibers hydrated with platelet-rich plasma and placed in the Yxoss CBR®mesh

5 – The titanium mesh was covered with a Geistlich Bio-Gide® Compressed membrane and platelet-rich fibrin (PRF) membranes

6 – week post-operative healing of surgical site shows increase in tissue width and no membrane exposure

CLINICAL SITUATION:

A 60-year-old female presented to the periodontics clinic at UTHSA for implant placement at sites #18 and #19. Upon clinical and radiographic examinations, the lower left edentulous ridge was diagnosed as a Siebert class III due to the presence of bucco-lingual and apico-coronal tissue defects. The treatment proposed included soft tissue grafting for increase of keratinized tissue followed by ridge augmentation using Yxoss CBR^®mesh and a mix of autograft, vallos^™ fibers, and platelet-rich plasma (PRP)

OUTCOME:

The vallos^™ fibers combined with autogenous bone and the PRP created a stable fibrin bone graft that could be easily molded and contained within the mesh. Hydration with PRP was progressive until the graft reached the desired consistency. Wound healing following ridge augmentation was uneventful. There were no signs of infection or membrane exposure at the site. Mesh removal and implant placement is planned at 6-months following ridge augmentation.

CLINICAL CASE

1 – Initial clinical presentation showing impacted #10 with anterior ridge deficiency.

2 – Initial radiographic presentation showing fractured/deficient alveolar bone and impacted #10.

3 – Facial and occlusal clinical views showing full thickness flap reflection with verticals #6 & #11 disto-facially.

4 – Facial and occlusal clinical views showing extraction #10 and ridge deficiency present.

Facial clinical view showing use of tacks to secure Geistlich Bio-Gide® membrane.

6 – Facial clinical view showing addition of Geistlich vallomix™ bone graft.

7 – Facial clinical view showing Geistlich vallomix™ bone graft added and secured with Geistlich Bio-Gide® membrane and tacks.

Clinical view showing primary closure using Vicryl™ sutures.

9 – Immediate post-surgical CT scan showing addition of proper bone volume.

10 – Clinical view showing appropriate healing at 2 and 4 weeks.

CLINICAL CASE

6 – Coverage with Geistlich Mucograft® Seal and sealed with sutures

10 – 6 months follow-up the digital implant planning was performed highlighting 3D adequate bone support.

11 – Initial presentation at the moment of implant placement.

12 – Full thickness flap elevation and initial osteotomy performed.

13 – Implant placed and cover screw positioned.

14 – Flap approximations using a PTFE suture after the implant was placed.

15 – Healing at 2 weeks after the implant placement.

16 – Overview of the radiographic sequence of the implant placement: A. The initial bone presentation. B. The guiding pin in position revealing the mesio-distal position. C. The final implant in place.

CLINICAL CASE

1 – The basis for planning implant therapy is clinical and radiological diagnosis with a CBCT scan.

2 – A precise 3-D planning model will be created based on CBCT data. Adaptations of the exact shape are possible, depending on the surgeon’s preference and feedback.

3 – The usual oral surgery and implantology hygiene provisions apply for the use of Yxoss CBR® intraoperatively. The same applies to patient medication.

4 – The opening incision should be designed in accordance with the extent, location and with respect to the anatomical structures of the region to be augmented.

5 – Subsequent steps are the preparation of a mucoperiosteal flap, debridement of scar tissue and the exposure of the defect. Sufficient blood supply of the flap is favored by a flap with a wide base.

6 – Autologous bone can be harvested from the usual intraoral donor sites and can be mixed with bone substitutes (e.g. Geistlich Bio-Oss®).

7 – The Yxoss CBR® is initially filled with autologous bone and bone substitute material (e.g. Geistlich Bio-Oss®).

8 – Yxoss CBR® is fixed on the existing residual bone with an osteosynthesis screw. The titanium screw can generally be introduced, depending on the intended position, through any opening of the titanium grid. The edges of Yxoss CBR® rest on the underlying bone tissue.

9 – A resorbable membrane (e.g. Geistlich Bio-Gide®) should be placed over the Yxoss CBR® to prevent ingrowth of soft-tissue and to support soft-tissue regeneration over the titanium frame.

10 – The wound should be closed completely whenever possible. The mucoperiosteal flap is positioned tightly but tension-free over Yxoss CBR® with single interrupted and deep mattress sutures. Pressure on the augmented crest has to be avoided. Dentures are not to be applied.

11 – Before reopening, clinical and radiological diagnosis are to be taken into consideration.

12 – Reopening of the augmented site approx. 4 to 6 months post surgery and depend on the defect geometry, at latest 9 months after initial surgery.

13 – After removing the fixation screws, Yxoss CBR® can be easily removed using preset breaking points

14 – Newly formed vital bone is regenerated up to the contour defined by the shape of the Yxoss CBR®.

15 – Insertion of implants into the augmented alveolar ridge according to the prosthetic position.

16 – Prosthetic restoration is carried out in accordance with the usual precautions.

17 – Follow-up and radiological evaluation should be performed according to the standardized recommendations of the respective dental societies.

18 – Clinical and radiological imaging of long-term outcome in this case at 5-year follow-up.

CLINICAL CHALLENGE:

The planning of the patient’s case takes local and general patient-specific risk factors into consideration according to the principles of backward planning for implant positioning.

AIM/APPROACH:

Highlights step-by-step the important procedures to regenerate the bone (horizontal and vertical) with the 3-D printing technology, Yxoss CBR^®.

CLINICAL CASE

1 – Baseline: multiple recession defect Miller Class I with keratinized tissue less than 3 mm on teeth #7 to #5.

2 – Coronally advanced flap preparation and elevation for sufficient release.

3 – Geistlich Fibro-Gide® is cut in half to 3 mm thickness.

4 – 3 mm Geistlich Fibro-Gide® is placed in the defect and absorbs blood immediately.

5 – Positioning of Geistlich Fibro-Gide® and fixation with single sutures (7-0 PGA sutures).

6 – Tension-free wound closure with sling sutures (6-0 PGA sutures).

7 – Suture removal 14 days post-surgery.

8 – Follow-up after 12 months: complete root coverage with Geistlich Fibro-Gide® is achieved.

9 – 2 year follow-up: complete root coverage with Geistlich Fibro-Gide®.

CLINICAL CASE

1 – Clinical presentation at baseline, with the patient exhibiting multiple gingival recessions associated with dental hypersensitivity.

2 – A coronally advanced flap was performed, with the interincisal papilla that was preserved.

3 – Xenogeneic cross-linked collagen matrix (Geistlich Fibro-Gide®).

4 – Application of the collagen matrix over the recipient site.

5 – Suturing of the collagen matrix to the de-epithelialized anatomical papillae using simple interrupted sutures (7/0 PGA).

6 – Stabilization of the two collagen matrices.

7 – The flap was coronally advanced and stabilized with sling sutures (7/0 polypropylene).

8 – Clinical outcomes at 6 months showing complete root coverage of the frontal teeth, and a significant reduction on the first premolars. The patient reported a substantial reduction of the preoperative dental hypersensitivity, together with high treatment satisfaction.

CLINICAL CASE

3 – 10 week post op healing. Root coverage achieved. Patient reports no problems and is pleased with the results. More follow ups to come.

2 – Sites at the day of the procedure after sutures placed. Tunnel between #23,24 and partial thickness flap raised between #23,22.

CLINICAL CASE

1 – Baseline: recession defect Miller Class I on tooth #11.

2 – Trapezoidal flap design: split-full-split flap elevation flap.

3 – Positioning of Geistlich Fibro-Gide® and fixation with single sutures (PGA 7.0 Sutures) at the base of the de-epithelialized anatomic papillae and in the apical mesial and distal angles.

4 – Tension-free wound closure with two sling sutures (PGA 6.0 Sutures).

5 – Suture removal 14 days post-surgery.

8 – Follow-up after 1 year: complete root coverage with Geistlich Fibro-Gide® is achieved.

9 – 3 year post-surgery: stable results with Geistlich Fibro-Gide®.

CLINICAL CASE

1 – Baseline frontal view: missing central incisor.

2 – Baseline occlusal view: The facial contour is flattened by physiological dimensional ridge alterations post-extraction.

3 – Full-thickness flap using one releasing incision in the distal aspect of the canine. Simultaneous contour augmentation using GBR was performed with autogenous bone chips to cover the exposed implant combined with a layer of Geistlich Bio-Oss®and Geistlich Bio-Gide®.

4 – Application of Geistlich Fibro-Gide® on top of the augmented area. A tension-free primary wound closure was obtained by a periosteal releasing incision.

5 – Suture removal 14 days post-surgery. Uneventful wound healing and an increase in soft-tissue volume.

7 – 2 months follow-up combined with abutment connection.

8 – Occlusal view of final restoration 2 years post-surgery.

9 – Final restoration 2 years post-surgery shows pleasing esthetics.

CLINICAL CASE

1 – Baseline before implant placement showing the soft-tissue deficiency.

2 – Implant surgery after implant placement showing the need for guided bone regeneration.

3 – Guided bone regeneration with Geistlich Bio-Oss® and Geistlich Bio-Gide®.

4 – Geistlich Fibro-Gide® was trimmed to the defect size and placed at full thickness (6 mm) on top of Geistlich Bio-Gide®.

5 – Wound closure (PTFE 5/0 sutures) by combining horizontal mattress sutures and single sutures in a double layer.

8 – Re-entry was performed 3 months post-surgery. Soft-tissue emergence profile at the time of final ceramic-crown delivery 4 months after implant placement.

9 – Clinical and radiographic situation 2 years after implant insertion.

CLINICAL CASE

1 – Baseline occlusal view: situation before removal of tooth #20.

2 – Tooth removal and extraction socket management with Gesitlich Bio-Oss® and Geistlich Bio-Gide®.

3 – Geistlich Fibro-Gide® was trimmed to the defect size, to augment the buccal and crestal soft-tissue area of the ridge.

4 – Geistlich Fibro-Gide® in place, augmenting buccal and crestal area of tooth #20 and buccal in the edentulous area tooth #21 to tooth #19.

5 – Immediate provisionalization of the implants.

6 – 3 weeks post-surgery: occlusal view of augmented area with created emergence profile.

7 – 3 weeks post-surgery: buccal view of augmented area with created emergence profile.

8 – Provisional reconstruction 6 weeks post-surgery.

9 – Final restoration 2.5 years post-surgery: soft-tissue thickness remains stable over time.

CLINICAL CASE

1 – Baseline buccal view: soft-tissue concavity at the dental implant site.

2 – Baseline occlusal view: volume deficiency on the buccal aspect.

3 – Adapting and trimming of Geistlich Fibro-Gide® to the defect size. Additional bevel cut performed for the area to be positioned close to the incision line.

4 – Position and fixation of Geistlich Fibro-Gide® to the buccal flap with horizontal mattress suture.

5 – Primary closure obtained by horizontal mattress and single interrupted sutures.

6 – 4 months follow-up: showing the healed soft-tissue after augmentation surgery.

7 – 4 months follow-up: provisional restoration. Notice volume recovery.

8 – Occlusal view before final restoration.

9 – 9 months follow-up: final restoration after soft-tissue augmentation surgery.

CLINICAL CASE

1 – Exposure of the alveolar ridge and buccal bone.

2 – Horizontal and vertical osteotomies of the distracted segment.

3 – The upward lift of the transported segment, achieving a height gain of 7 mm.

4 – Geistlich Bio-Oss® Block is trimmed in a dry state with a piezo surgical device to the required dimension and shaped to completely fit into the recipient site.

5 – The coronally shifted segment is fixed with miniplates and miniscrews and thus immobilizes also the biomaterial block.

6 – The coronally shifted segment is fixed with miniplates and miniscrews and thus immobilizes also the biomaterial block.

7 – Intra-operative situation following implants insertion 4 months after interpositional grafting.

8 – Periapical X-ray evaluation immediately after implant insertion.

CLINICAL CHALLENGE:

Insufficient alveolar ridge height for implant placement and proximity to the alveolar nerve
Autologous bone harvesting is associated with patient discomfort

AIM/APPROACH:

Interpositional grafting with Geistlich Bio-Oss^® Block for vertical augmentation
Alveolar ridge volume preservation and minimizing patient morbidity

CLINICAL CASE

1 – Preoperative radiograph depicting the severe bony atrophy in the posterior mandible.

2 – Fixation of the pre-formed osteosynthesis plate with miniscrews.

3 – Augmentation with autologous bone harvested from the angular region of the mandible and mixed with Geistlich Bio-Oss®.

4 – The grafted site including the osteosynthesis plate is covered with Geistlich Bio-Gide® and the tensile collagen membrane is pinned down. Thus, the augmented site is accurately covered and stabilized.

5 – In order to obtain primary wound closure, a double-layered suturing technique is used by combining a horizontal internal mattress and a coronal single stitch technique.

6 – Implants are inserted 6 months after augmentation and the healing abutments are connected to the implants.

7 – Lateral view of the final prosthetic restoration 6 months after implant placement.

8 – Intraoral radiograph 15 months after augmentation procedure showing a stable bony situation.

CLINICAL CHALLENGE:

Severely atrophied alveolar ridge with insufficient bone volume for implant placement
High complication rates and patient discomfort associated with large augmentations when using autologous bone grafts

AIM/APPROACH:

3-dimensional augmentation of alveolar ridge by the fence technique for implant placement
At the same time reducing complication rates and patient discomfort

CLINICAL CASE

1 – Occlusal view of the ridge after flap elevation.

2 – Longitudinal split of the alveolar crest by use of piezo-surgical instruments.

3 – Two implants are placed in the expanded crest.

4 – The split around the implants is filled with a mixture (1:1) of autologous bone chips from the retromolar area and Geistlich Bio-Oss®.

5 – The augmented ridge is covered with a Geistlich Bio-Gide® membrane before closure of the soft tissue.

7 – Occlusal view of the prosthetic outcome.

8 – X-ray findings 6 months after implant placement.

CLINICAL CHALLENGE:

Insufficient alveolar ridge width for implant placement
Autologous bone is subject to resorption and may lead to loss of volume

AIM/APPROACH:

Ridge Split procedure in combination with Geistlich Bio-Oss^® and Geistlich Bio-Gide^® for horizontal augmentation
Preservation of the alveolar ridge volume

CLINICAL CASE

1 – 3D reconstruction from CBCT images showing horizontal maxillary atrophy at the two-teeth gap.

2 – Intraoperative view of the atrophied anterior maxillary site. Tenting screws are placed to support the collagen membrane.

3 – Application of a mixture (1:1) of autologous bone chips from the retromolar area and Geistlich Bio-Oss®.

4 – Coverage with a double layer of collagen membrane Geistlich Bio-Gide®.

5 – Tension-free, primary wound closure by mattress and single interrupted sutures.

6 – Situation at re-opening after 6 months showing vital bone and reconstructed ridge contour.

7 – Guided implant placement in regenerated bone with stent (additional implant placement at position 22).

CLINICAL CHALLENGE:

Insufficient alveolar ridge width for implant placement
Donor site morbidity after autologous bone block harvesting and resorption of autologous bone

AIM/APPROACH:

Horizontal alveolar ridge augmentation with Geistlich Bio-Oss^® and Geistlich Bio-Gide^®
Minimizing autologous bone harvesting and resorption protection

CLINICAL CASE

1 – Patient with missing teeth 3, 4 and 5 in combination with horizontal and vertical atrophy. Situation incompatible with ideal and prosthetically guided implant insertion.

2 – Initial CBCT showing vertical and horizontal bone deficit.

3 – 3-D model obtained from CBCT with the corresponding Yxoss CBR® design.

4 – Final titanium scaffold ready for use.

5 – Exposure of the bone defect with full thickness flap.

6 – Fixation of Yxoss CBR® filled with a mix of autologous bone chips and Geistlich Bio-Oss® using two titanium screws.

7 – Coverage with a Geistlich Bio-Gide® membrane.

8 – Tension-free hermetic suture of the flap.

9 – After 8 months, the adequate rooting of the bone graft is assessed by CBCT and the insertion of the implants is planned in a prosthetically guided manner.

10 – 8 months after the GBR the scaffold is removed and two endosseous implants are inserted.

11 – Radiography with three elements supported by implants.

12 – Final prosthetic reconstruction 3 months after implant placement, without the need of a temporary interim solution.

CLINICAL CASE

1 – Initial clinical situation showing an extended horizontal and vertical bone gap at former positions of teeth 3 and 4 which were extracted 8 weeks earlier.

2 – CBCT showing a deficient vestibular contour and the corresponding bone defect. 3-D design of Yxoss CBR® derived from the patient’s anatomy.

3 – Surgical situation with horizontal and vertical bone defect.

4 – After testing the adaptation of Yxoss CBR® to the defect, it is filled with a graft consisting of 30% autologous particulate bone and 70% granules of Geistlich Bio-Oss®.

5 – Yxoss CBR® fixed with titanium screws.

6 – Adaptation of Geistlich Bio-Gide® over the structure. Complete, tension-free wound closure will follow.

7 – Sites at the day of the procedure after sutures placed. Tunnel between #23,24 and partial thickness flap raised between #23,22.

8 – Radiographic situation after 6 months of healing, before reopening.

9 – Insertion of two implants (Straumann® BLT). The resonance frequency measurement shows ISQ values of 70-75.

10 – Insertion of the healing abutments and adaptation of the flap.

11 – Soft tissue maturation 12 weeks after implant insertion.

12 – Clinical situation after prosthetic finalization, 18 months after surgery. X-ray shows stability of marginal bone levels.

CLINICAL CASE

1 – Large horizontal and vertical bone defect in region 5-12; deficit emerging from many years of wearing mucosa-supported dentures.

2 – 3-D design including 3-D model, grafting volume, Yxoss CBR® and implants.

3 – 3-D Design including 3-D model and Yxoss CBR®.

4 – Initial clinical situation before opening of the soft tissue.

5 – Presentation of bony situs with a full-thickness flap (ridge incision).

6 – Titanium scaffold filled with 100% Geistlich Bio-Oss® and placed onto bone defect. Fixation performed with 4 mini-screws in the buccal area.

7 – Soft tissue situation after 6 months of healing.

8 – Careful separation of Yxoss CBR® into two parts at predetermined breaking points (Easy Removal Design®). Pilot drill performed through built-in holes according to backward planning principle.

9 – 4 implants placed in positions 5, 7, 10 and 12 to support the prosthesis. Bleeding out of the bone shows a good vascularization.

10 – Panoramic X-ray 6 months after the augmentation. In the meantime, 4 additional implants have been placed in the lower jaw.

CLINICAL CASE

1 – Radiographic image showing the vertical bone deficit in the left mandible.

2 – Clinical situation before opening the area.

3 – Incision for the creation of a poncho flap.

4 – Starting in the retromolar area the incision is directed toward the distal region of tooth 23.

5 – Cortical bone is removed with the trephine, crushed and mixed with Geistlich Bio-Oss® (50:50).

6 – Successive application of Geistlich Bio-Gide®.

7 – Dehiscence after 1.5 months. The soft tissue was de-epithelialized and a free gingival graft was sutured to protect the exposition. Dehiscence may occur but usually heals spontaneously after appropriate cleaning.

8 – After 6 months, the ridge incision is applied to access the 3-D titanium scaffold.

9 – Buccal view of the regenerated bone. Even though there was dehiscence, the bone was regenerated satisfactorily.

10 – Four implants are inserted and the soft tissue is healed showing the contour provided by the good adaptation of the provisional prosthesis.

11 – Clinical situation after the final prosthesis and the soft tissue frenum removal.

CLINICAL CASE

1 – Clinical situation in the posterior maxilla depicting a large buccal defect in the edentulous area.

2 – Fixation of the autologous block from the symphysis.

3 – Contouring of the grafted site with Geistlich Bio-Oss®.

4 – The augmented area is covered with the collagen membrane Geistlich Bio-Gide®.

5 – Primary wound closure is accomplished with single interrupted sutures.

6 – Clinical aspect of the augmented ridge with no signs of block resorption.

7 – Implant placement 3 months post augmentation.

8 – Long-term follow-up showing stable peri-implant bone level 3 years after implant placement.

CLINICAL CASE

1 – The preoperative radiograph displays the vertical bone defect in the left mandible and thus, insufficient vertical bone volume to allow implant placement.

2 – Yxoss CBR® is planned based on the preoperative CBCT data.

3 – Opening the defect site using the ridge incision technique. The titanium scaffold fits the bone defect precisely during the augmentation procedure.

4 – The titanium scaffold is filled with 50% autologous bone and 50% Geistlich Bio-Oss®. Fixation is performed with one titanium screw in vestibulolingual direction.

5 – A collagen membrane (Geistlich Bio-Gide®) is used to provide an additional barrier for bone regeneration.

6 – Stable soft tissue situation after 6 months with no complications during the healing period. After reopening, bone is regenerated to the contour defined by the titanium scaffold.

7 – The bone is completely regenerated in the correct three-dimensional orientation. This is also visible in the respective CBCT. Implant placement is now possible.

8 – Two implants were placed with good primary stability. The vertical bone regeneration is also visible in the CBCT data.

9 – Postoperative panoramic radiograph after implant placement.

10 – Clinical situation 3 months post implant insertion.

11 – Final prosthetic reconstruction 6 months post implant insertion and 16 months post regenerative surgery.

12 – Final prosthetic reconstruction 16 months post regenerative surgery.

CLINICAL CASE

1 – Pre-operative assessment demonstrating significant bone loss, prior to vertical ridge augmentation.

2 – Labial view of the posterior mandibular defect site. Cortical bone was perforated to increase the blood supply.

3 – RPM™ was secured on the lingual side prior to applying a 1:1 mixture of autogenous bone and Geistlich Bio-Oss®.

4 – RPM™ was secured over the bone graft with titanium pins and screws.

5 – Geistlich Bio-Gide® is placed on top of RPM™ to prevent early soft tissue ingrowth while allowing for graft vascularization.

6 – Labial view of the soft tissue 9 months after the vertical bone augmentation.

7 – RPM™ exposed at 9 months, following flap elevation.

8 – Labial view of the regenerated surgical site at 9 months demonstrates well vascularized bone.

9 – Occlusal view of the regenerated surgical site at 9 months demonstrates well vascularized bone.

10 – Implant placement in the newly regenerated bone.

Geistlich Fibro-Gide® (15x20x6mm) was placed on top of two implants, to increase soft tissue thickness.

12 – Periapical x-ray 1 year post-operatively, demonstrates implant stability and mature bone formation following vertical bone augmentation and soft tissue thickening.

CLINICAL CASE

Initial situation, patient presented with radiographic and clinically traditional signs of peri-implantitis, including bleeding on probing, suppuration, radiographic progressive bone loss and clinical pathologic probing depths.

Mechanical debridement was achieved using titanium scalers, an ultrasonic device with an implant protective cap and titanium brushes to remove all of the visible contaminants of the implant surface. Citric acid was then placed on shreds of a non-woven gauze and applied to the surface for approx. 1min. Copious irrigation was done using saline solution and the surface was ablated using the Er:YAG laser at 20pps/50mj.

After the surface was prepped and no signs of residual granulation tissue was noted, the defect was grafted with Geistlich Bio-Oss®. Attention was given towards not augmenting beyond the bony envelope.

A protective Geistlich Bio-Gide® membrane was placed over Geistlich Bio-Oss®.

Geistlich Fibro-Gide® was placed over Geistlich Bio-Gide® to enhance soft-tissue volume and quality. Geistlich Fibro-Gide® was trimmed and adapted to the defect site ensuring a tension free closure.

Geistlich Fibro-Gide® was place on the top of the bone graft to enhance soft-tissue thickness. Geistlich Fibro-Gide® is porous. We can observe the rapid penetration of blood through the matrix.

Closure with a tension-free flap was achieved by releasing incisions and secured using 4-0 chromic gut sutures.

1.5 year post-operative photo and radiograph show the healing of the soft-tissues with no signs of peri-implantitis and adequate tissue thickening. Radiographic bone levels have maintained stable over the course of the year.

CLINICAL CASE

Pre-operative condition: Note that the gingival recession of 3-4 mm is evident as is the cervical root abrasions. The interdental papillae completely fills the embrasure space.

Incision design showing the sulcular incisions with horizontal incisions across the interdental regions ending with a remote oblique vertical releasing incision distal to the first bicuspid tooth.

Geistlich Fibro-Gide® is trimmed in a dry state to 10 x 15 x 6mm. The corners were trimmed for better adaptation and the matrix was then hydrated in sterile saline solution.

The interdental papillae were de-epithelialized and Geistlich Fibro-Gide®was placed over the exposed roots extending onto the bone. Geistlich Fibro-Gide® was not secured with sutures.

Internal periosteal releasing incision was made to allow tension-free coronal advancement of the buccal flap to completely cover Geistlich Fibro-Gide®.The flap was secured with 5-0 Monocryl® sutures.

1-week post-operative visit: the healing looks good and sutures are intact. There was a small soft-tissue dehiscence at the buccal margin of the canine tooth.

Healing progressed well at 2 months post-operatively and the dehiscence defect seen at 1 week appears to be healing. Soft-tissue thickness is also evident at this stage.

At 6 months, 100% root coverage has been achieved. Note the increase in keratinized gingiva at the canine tooth where there was previously delayed healing. The patient is happy with the esthetic and functional outcome.

CLINICAL CASE

1 – Baseline: recession defects on teeth #19 to #22 in the lower left quadrant. Exposed root surfaces of these teeth were thoroughly scaled and root planed before surgery.

2 – A full thickness muco-gingival tunnel was prepared through a minimally-invasive vestibular access incision apical to the teeth with gingival recessions.

3 – Geistlich Fibro-Gide® was cut into small pieces in a dry state using a scalpel.

4 – Insertion of Geistlich Fibro-Gide® into the subperiosteal tunnel.

5 – Geistlich Fibro-Gide® in situ: the gingival margin had been coronally advanced and stabilized after pieces of Geistlich Fibro-Gide® were placed.

6 – 1 week post-surgery: anchoring sutures were left in place for 1-2 weeks.

7 – 2 weeks post-surgery: anchoring sutures in place.

8 – 2 weeks post-surgery: removal of anchoring sutures.

9 – 7 months post-surgery: complete recession coverage.

CLINICAL CASE

1 – Baseline frontal view: missing central incisor. Implant visible through mucosa due to thin biotype.

2 – Baseline occlusal view: soft-tissue deficit in the buccal and occlusal area.

3 – Flap elevation on the buccal side using a full flap crestally and a split flap buccally.

4 – Adaption of Geistlich Fibro-Gide® to the defect size.

5 – Palatal island flap prepared to allow for tension-free wound closure. Geistlich Fibro-Gide® in situ, immobilized with a mattress suture.

6 – Tension-free wound closure using single interrupted sutures (Dafilon 5-0, Braun).

8 – 6 months follow-up: final crown in place.

9 – 2.5 year follow-up shows stable soft-tissue conditions.

CLINICAL CASE

1 – Pre-operative view of the atrophied ridge.

2 – Application of a 1:1 mixture of autologous bone and Geistlich Bio-Oss®.

3 – Geistlich Bio-Gide® is tightly fixed and pinned, thus immobilizing the particulate graft. The sausage-like augmentation allows extended horizontal augmentation.

4 – Primary wound closure is obtained with a combination of mattress and single-interrupted sutures.

5 – Sufficient amount of augmented bone for implant placement 8 months after augmentation. Implants are placed in a submerged procedure.

6 – Insufficient vestibular depth and keratinized tissue after alveolar ridge augmentation.

7 – Application of a keratinized strip towards the vestibulum and Geistlich Mucograft® over the augmented area where it is left exposed for healing.

8 – Situation before reopening for abutment connection after 3 months showing increased vestibular depth

CONCLUSIONS:

Geistlich Mucograft® with a keratinized tissue strip was utilized to increase vestibular depth and gain additional keratinized tissue.
Augmentation of severely atrophied alveolar ridge provided sufficient bone for implant placement 8 months following augmentation.